Individual
JACK HENRY JAKE LONDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RBT
Contact information
Practice address
4112 FIELDSTONE RD, SUITE B, CHAMPAIGN, IL 61822-6182
(888) 308-3728
Mailing address
245 W ROOSEVELT RD, WEST CHICAGO, IL 60185-3739
(888) 308-3728
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
20142911
—
Other
Enumeration date
04/05/2021
Last updated
04/05/2021
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